Chest
Volume 131, Issue 6, June 2007, Pages 1865-1869
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ORIGINAL RESEARCH
COMMUNITY-ACQUIRED PNEUMONIA
Misdiagnosis of Community-Acquired Pneumonia and Inappropriate Utilization of Antibiotics: Side Effects of the 4-h Antibiotic Administration Rule

https://doi.org/10.1378/chest.07-0164Get rights and content

Background

The 2003 Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend the initiation of antibiotic therapy within 4 h of hospitalization. This quality indicator has been linked to the incentive compensation of third-party payers to hospitals. We evaluated the impact of this recommendation on the diagnosis of CAP and the utilization of antibiotics.

Methods

All patients with a hospital admission diagnosis of CAP before publication of the guidelines (January to June 2003) and after publication of the guidelines (January-June 2005) were included. We collected data on clinical signs and symptoms on presentation, chest radiograph findings, blood cultures prior to therapy with antibiotics, time to antibiotic administration, pneumonia severity index (PSI) score, confusion, urea, respiratory rate, BP, and age ≥ 65 years (CURB-65), and mortality.

Results

A total of 518 patients were included in the study. More patients in 2005 had a hospital admission diagnosis of CAP without radiographic abnormalities compared to 2003 (2005, 91 patients [28.5%]; 2003, 41 patients [20.6%]; p = 0.04), and more patients received antibiotics within 4 h of triage (2005, 210 patients [65.8%]; 2003, 107 patients [53.8%]; p = 0.007). Blood cultures prior to antibiotic administration increased (2005, 220 patients [69.6%]; 2003, 93 patients [46.7%]; p < 0.001). However, the final diagnosis of CAP dropped to 58.9% in 2005 from 75.9% in 2003 (p < 0.001). The mean (± SD) antibiotic utilization per patient increased to 1.66 ± 0.54 in 2005 compared to 1.39 ± 0.58 in 2003 (p < 0.001). There were no significant differences in PSI or CURB-65 scores, or mortality.

Conclusions

Linking antibiotic administration within 4 h of hospital admission (as a quality indicator) to financial compensation may result in an inaccurate diagnosis of CAP, inappropriate utilization of antibiotics, and thus less than optimal care.

Section snippets

Study Design

The study was performed in a 608-bed teaching hospital with 112,000 annual ED visits. We performed a retrospective study of all patients who were admitted to the ED with a diagnosis of CAP over two 6-month periods prior to the publication of IDSA guidelines2 (January to June 2003) and 1 year after publication (January to June 2005). We obtained an institutional review board approval prior to starting the study.

Patients

All patients ≥ 21 years of age who were admitted to the ED with a primary or

Patient Characteristics

A total of 734 patients (2003, 291 patients; 2005, 443 patients) were initially identified with an ED admitting diagnosis of pneumonia. Of these, 518 patients (2003, 199 patients; 2005, 319 patients) were included in our study. The reasons for study exclusion were age < 21 years (n = 118), incomplete data (n = 53), transfer from another acute care hospital (n = 27), or patients died, left the hospital against medical advice, or were given palliative care before a definite diagnosis was made (n

Discussion

The association between early antibiotic administration for CAP and improved outcomes has been reported in two large retrospective studies. Meehan et al3 found that the administration of antibiotics within 8 h of arrival at the hospital for Medicare patients was associated a lower 30-day mortality rate (odds ratio, 0.85; 95% confidence interval, 0.75 to 0.96). As a result, the Medicare National Pneumonia Project, from 1999 through 2002, promoted the administration of antimicrobial agents within

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This study received the Kass Award and was presented at the 44th Annual Meeting of the Infectious Diseases Society of America, October 2006.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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